What should a therapist do under the following circumstances?
A 40 year old patient male) comes for initial consultation because he is unhappy with his life situation in regard to relationships and his career. There is no evidence of psychosis, severe depression or suicidal ideation. The patient has mild obsessive symptoms and there are various personality traits related to his family experiences. The patient is well motivated for psychotherapy and appears to have capacity for good insight.
The patient has occasional drink on weekends and no drug issues EXCEPT that he smokes marijuana most evenings and enjoys the experience. He also acknowledges that he does “ drive stoned” but he believes he is a good driver and has never had an accident. When this is explored further he acknowledges that he understands that his reaction time might be minutely slowed but he knows he is a better driver than most people. He expects to come for weekly psychotherapy and will drive about ½ hour to my office for an evening appointment. He also drives to work daily for about 45 minutes and sometimes will have joint before he drives home.
1- Would you insist that you cannot treat him if he is engaging in dangerous behavior by driving stoned? Explain
2- Would you make this a high priority issues to work on in therapy whether the patient bring it up or not ? Explain
3-Would you deal with this issue as you would any other topic depending on his associations and current conflicts as well as transference issues?
4- Would the answer to any of the above question be different if the patient were a moderate drinker and frequently drives while “buzzed“ or intoxicated?
My Memories of “9/11” on the 15th Anniversary of September 11, 2001
If you have any memories of 15 years ago you certainly remember where you were, what you did and how you felt when terrorists took over two large airline planes filled with passengers and crashed them into the World Trade Center in New York leading to the collapse one of towers and the death of thousands of people.
I would like to use this blog to recall my memories and thoughts about where I was, what I did and how I felt. As is often the case in recollecting traumatic events, I may not have every detail correct but this is how I recall things. I should state that I while I was in New York I was not near ground zero at the time and no one close to me was killed or injured.
As a psychiatrist, I previously had some experience in working with people who were traumatized. I was a consultant to a burn and trauma unit of a hospital and had written a book about this subject. A few years previously I was part of a team that studied the psychological effects of a major plane crash in Dallas and I had studied the psychological impact on emergency workers of doing their work, as well as the impact on members of the media who cover such events. I have had occasion to write and speak on related subjects before and after 9/11.
I was in my office at New York Medical College/Westchester Medical Center, which is a suburb of New York City. My secretary told me that she had heard that a plane had crashed into the World Trade Center. This immediately brought to my mind a childhood memory of when a small plane had crashed into the Empire State Building in New York City. My father was a New York City policeman at the time and called in the event to emergency services. He subsequently brought home, a small piece of twisted metal and wires that I was told were part of the plane. I was soon to learn that 9/11 was a much greater catastrophe than that event.
The nearest television to my office was on a closed psychiatric unit in the hospital not too far from where I was located. I made my way there and in the large day room all the patients and staff were watching a medium sized television. I quickly appreciated the magnitude of this event when shortly after I entered the room and focused on the TV, I saw pictures ofone of the tallest buildings in the world collapse on live TV. As I recall the experience, there was only a quiet murmuring or perhaps some groans coming from myself and the people viewing this together. I should point out that this was a closed psychiatric unit with acute severely mentally ill patients some of who would usually be in an agitated psychotic state, perhaps with hallucinations. I don’t remember any such manifestations being shown. It was almost as if many of the patients were jolted back to reality by this event. I didn’t study this phenomena but it reminds me of an experience that I had in my first year of psychiatric training. I was assigned to an inpatient unit at another psychiatric hospital in New York City when there occurred a highly unusual city wide black out of all power. As I recall, it was in the evening and the hospital basically went dark with no or very little emergency power for lights for several hours . I subsequently wrote one of my first papers examining the reactions of the various patients to this unusual circumstance.
While initially we had no idea of what was the cause of this plane crashing into the World Trade Center Building or that there were other planes involved. It was apparent that many people were killed although there was no indication initially that it would be in the thousands and that people were actually jumping out of windows to their death rather than being burned to death. As the magnitude became apparent, my natural instinct as was that of others, was to be concerned about my loved ones who worked in Manhattan. While I didn’t think that they would be at that location I made phone calls to assure that they all were safe. Many people did not receive good news as they checked with their family and friends. One man who I knew quite well, was director of clergy services at the hospital, lost his son at the World Trade Center. At that time I lived in one of many suburban communities outside of New York City where many people commuted to work by train. That evening there were many cars in the train station parking lot that were not picked up by people who had perished that day. Photographs of those cars that were not claimed by their owners that evening stands out in my memory.
My wife who worked at a major hospital in Manhattan related how her hospital immediately had gone to it’s emergency plan waiting to receive large numbers of victims with injuries that were expected. Even the suburban hospitals such as mine went on to that mode where surgeons were called in and all personal were on standby expecting to deal with the overflow of casualties from this tragedy. But despite the approximately 3000 fatalities, I understand that there were very few injuries. The ash floating down on the city may have caused some minor medical problems.
In the days and weeks following this horrific event there was this very unusual phenomena of there being many posters on walls, trees, light poles etc not only downtown but in other parts of the city. The theme of these posters was looking for a lost relative. There would be a photograph and a brief description usually stating that the person worked in the World Trade Center and was missing. There would be a phone number to call if anyone knew about this missing person. The reality was that there were no missing people. The very few people who may have visited a medical facility were identified and all of these “ lost “ people had obviously died. However, understandably their loved ones in many cases could not initially accept what had happened and were trying to maintain hope . Over the ensuing days and weeks many of the posters remained in place but their makers had crossed out the word “ Missing” and there were words about how the poster was a memorial to them. Often there were flowers left next to them. I also recall passing a fire station from where many firemen had perished after they had entered the tower to save victims and had been inside when it collapsed. It was shrouded with black draping and an appropriate sign paying tribute to the lost heroes of that fire station.
I believe it was on Pier 92 in downtown that a massive social service outreach program was set up to assist the family and friends of people believed to be killed in the tragic event. There were places for people to register that they had lost a loved one. In many cases the remains of victims would not be found . There were psychological services offered to the distraught people many of whom were grieving lost loved ones.
I recall it was at this location that on the third or fourth day after 9/11 I was asked because of my previous experience in working with the media around traumatic events, to run a “debriefing group “ for members of the media who had been working day and night on this tragic news story. Many of them had spent hours interviewing grieving friends, relatives and the colleagues of the firemen who had died. They had seen and photographed the gruesome scenes of dead bodies and the partial remains. Some had photographed the falling bodies of the jumpers who chose to die this way rather than by fire. They spent hours talking on and off the air about all the details of news story, edited their material and in many cases went without or with very little sleep since the story broke. In the earlier days of “debriefing” victims of trauma the psychological approach had been to allow each person in the group to recount their experience. We had subsequently learned that such an approach often re-traumatized individuals who heard other people’s stories in the group. The approach now was more geared to explain to people about the symptoms which they might be having or might have in the near future and suggestions about how to deal with them as well as allowing them to ask any questions. We would also try to identify people having significant difficulties and offer them more individual help. In the course of running this group I mentioned how comforting members of the media particularly TV commentators might be to the public as they explain what is happening and try to keep the audience calm. Illustrating this point, I told them about a phone call I had just had with a family member who told me of a dream she had that Peter Jennings ( the ABC anchor) was talking and comforting her about the event. In the group I was speaking with was Peter Jenning’s TV producer who worked very closely with him and said she was sure that he would appreciate that story and she would tell it to him that evening. You can imagine how surprised my relative was when I called her and told her that Peter Jennings would soon know about her dream.
By coincidence I had been scheduled to do a Grand Rounds Presentation at a hospital in Manhattan not too far from ground zero 10 days after 9/11. It was pointed out to me that you could previously see the fallen tower from the room in which I was speaking. I don’t recall what the original topic was but we altered it to focus on that unforgettable event that had occurred in their backyard.
For many years I have been a very small part of the large number of mental health professionals writing and teaching about how our profession can be helpful in dealing with mass traumatic events. As a therapist I realize that many people have their own individual traumatic experiences that impact them and often alter their lives. These personal traumatic events can be just as meaningful and life changing as a big event that affects large numbers of people .
While I was very fortunate not to have been seriously traumatized by 9/11, but still the fear and worry that I had living through it along with millions of Americans is obviously imprinted in my mind. Recounting it now in this blog relieves some of the pain that is still associated with that memory.
Michael Blumenfield, M.D.
Moving Images: Psychoanalytic Reflections of Film, by Andrea Sabbadini, Routledge, London and New York, 2014, 140 pp.
While reading this book, I kept pondering the question of who would be the best audience for it. The author, Andrea Sabbadini, is a psychoanalyst who is extremely knowledgeable about film, especially classic European movies. His stated goal for the book is to offer discussion of films from a psychoanalytic perspective and in the process of doing so, to use the films in order to illustrate a number of psychoanalytic ideas and to convey a sense of what analytic work consists. Anyone who is familiar with many of the movies discussed in this book and understands psychoanalytic and psychodynamic theory would be the ideal audience for it. However, even knowledgeable psychoanalysts with out having seen these films would find it difficult to relate to the book. Similarly, students of cinema who may have seen the films mentioned, would probably get lost in the erudite psychoanalytic discussion presented in this book. Unfortunately, that would seem to leave a very small audience for this book. However, I do see an important value for it which I will discuss at the conclusion of this review.
This 140-page soft-covered book has six chapters which I will list below with two of the several movies discussed in each chapter.
Chapter 1: “A Young Profession: Films on Psychoanalysis” Spellbound (Hitchcock, 1945)
Il Postino (Radford, 1994)
Chapter 2: “…and the Oldest One: Films on Prostitution” Nights of Cabiria (Fellini, 1957)
Belle de Jour (Buñuel, 1967)
Chapter 3: “The Young Ones: Films on Children” The Spirit of the Beehive (Erice, 1973)
German Year Zero (Rossellini, 1948)
Chapter 4: “…and Slightly Older Ones: Films on Adolescents” Heavenly Creatures (Jackson, 1994)
City of God (Meirelles, 2002)
Chapter 5: “Between Eros and Thanatos: Films on Love” A Pornographic Affair (Fonteyne, 1999)
Amores Perros (Inarritu, 2000)
Chapter 6: “Watching Voyeurs: Films on Scopophilia” Rear Window (Hitchcock, 1954)
Peeping Tom (Powell, 1960)
The book opens with a discussion of films about psychoanalysis in which the author touches on how the psychoanalytic profession has been depicted in numerous movies, including a mention of the television series In Treatment (2010). There are several flms discussed in this chapter where Freud himself, and other well known analysts, were depicted. We also learned that Freud showed very little interest in the movies of his day and stated in a letter that he did not believe psychoanalytic ideas could be represented by cinema. Alfred Hitchcock’s Spellbound, which starred Gregory Peck and Ingrid Bergman, is described in this chapter as perhaps the most famous of all films about psychoanalysis. Sabbadini spends five pages discussing this film and how this whodunit movie included discussion of dream analysis, anxiety inducing situations, psychopathic devices of amnesia (repression), and guilt complexes. There is also a discussion of how the camera work, light effects, sound track, and editing create the dream-like psychological atmosphere that the director wished to achieve. In the movie Il Postino, Sabbadini justifies that while it is not actively about the psychoanalyst or analysand, the close relationships that gradually develop between Marino, the postman, and Neruda, the poet, shared many features with what normally takes place in our psychoanalytic consulting rooms.
In the chapter about films and prostitution, the author reviews the social complexities surrounding the selling and buying of sexual favors for money. He even considers a common fantasy that there is a close association between prostitution and psychoanalysis. He uses Fellini’s movie, Nights of Cabiria, to discuss the concept of a rescue fantasy. Fetishism and masochism are also analyzed in this chapter in some detail. Catherine Deneuve’s character Severine in Belle de Jour is examined and at one point the author even postulates that the house of prostitution is the metaphoric antithesis of marriage and has the unconscious function of keeping the latter alive and with it the normality it symbolizes.
Chapter three is the longest chapter and discussed fillms about children, which should not be surprising coming from a psychoanalyst who appreciates the importance of early life experiences. The Spirit of the Beehive was an internationally acclaimed film which was described as dealing with innocence, illusions, and isolation. It focuses on two young girls growing up in the Spanish countryside. This movie deals with the fantasy that they have of monsters which occurs after they see the classic horror movie Frankenstein. This certainly can be related to contemporary young women who are constantly bombarded with such horror films. The author examines how the two children’s fantasy world and magical thinking is skillfully explored by this movie movie. The film Germany Year Zero approaches children in a completely different manner. Rosselini visited postwar Germany in 1947 apparently without any story to tell but trying to answer his own troubled question, “The Germans were human beings like everyone else. What could have led them to this disaster?” Sabbadini describes how this film develops the answer to this question from the point of view of children as they find themselves forced by circumstances to behave like adults.
It is only natural that the author progresses to the next chapter and discusses films on adolescents. He tries to put a perspective on child development theory by noting that it is only in the course of the last 30 or so years that a radical shift has taken place in relation to our understanding of adolescence. One of the films which he focuses on in this chapter is Heavenly Creatures where two adolescent girls, when not immersed in their fantasies, would become obsessed with a plan to murder the mother of one of them. This movie is actually based on the diaries of a person in a real life event which took place in New Zealand. Sabbadini describes how the film attempts to show the conflict between adults and adolescent children. The Oedipus complex and “passing phases of homosexuality” are some of the themes analyzed in this movie. Another film discussed in this chapter is City of God which is also based on an actual event that happened in Rio de Janeiro in the 1960s and 1970s. It looks at the role of young people in the Brazilian slums and is described as a “part tender Coming of Age film and part Gang-Warfare Epic.” The author uses this film to further expound on Oedipus theory.
Chapter 5 tries to look how the cinema often tackles issues of love. The author notes how films have explored most variations of this theme often throwing new light on the more bizarre and unusual aspects of it rarely considered anywhere else. He also states that psychoanalysis has done likewise focusing more often on the pathological deviant or perverse side of it rather than the so-called normal one. Sabbadini uses A Pornographic Affair and the relationships of the two characters Elle and Lui to study the deeper emotional meaning of their liaison. He discusses psychoanalytic constructs to understand them such as triangular constellations, regressive tendencies, voyeuristic fantasies (of the audience), and the unseen pornographic components of the main characters’ love affair. Sabbadini returns to the concept of the rescue fantasy as he then analyzes the Mexican film, Amores Perros. This movie consists of three stories which he tells us involve transgressive passion and almost intolerable violence as well as profound humanity. He breaks down each story and explains and interprets the fantasies involved. He explains how he feels that there is a universal fantasy and an important emotional complex both in the conscious and unconscious and that it is often related to primary narcissism.
In the final chapter titled “Watching Voyeurs, Films on Scopophilia” perhaps the most interesting chapter in the book. Sabbadini recognizes the cinema goer or film lover as a voyeur and he quotes Freud stating that the scopophilia drive is autoerotic. Therefore the movie-going experience is a source of both voyeurism and exhibitionism. By bringing the viewers into the equation, he is in a sense recognizing one of the analyst’s most powerful instruments and that is a recognition and utilization of our countertransference. One of the examples that he uses is Hitchcock’s Rear Window. In this film, through one of the main characters played by James Stewart, we watch through his rear window, what goes on in an apartment house opposite his home. Sabbadini discusses that what we see through the voyeur’s eye is a projection of our own desires. He also describes this movie as a dream. He goes on to use Freud’s essays on the theory of sexuality to analyze the movie and also brings in the witch hunts of the McCarthy era which were occurring when the film was made and he believed may have influenced it. There is no shortage of films for Sabbadini to use to further explore this topic. He analyzes the film Peeping Tom which allows him to discuss an array of different forms of deviant sexuality, psychopathology, scopophilia, obsessions with pornography, and sadism, not to mention a further description of the presence of a deep depression underlying everything else.
I believe that the real value of this book will be as a textbook for the study of the cinema from a psychoanalytic point of view. A group of psychoanalytically minded people could choose one of the films mentioned in this book for each group discussion and view it individually or together prior to a discussion of it. They could consider the observations and the thoughts of Sabbadini as well as their own reactions and interpretations of the film viewed. One person could lead the discussion of each film. Since most members of such a group would likely not have previously seen most of these films, this would enable them to now view them and participate in a study of them. I am sure these films are readily available on Netflix.
A second group that may want to use this book as a guide to understanding the films discussed in it might be film students or people who enjoy classic films. Assuming that most of these people who join such a discussion group would not be psychoanalytically trained, the leader or guide for such a discussion group could be a psychoanalyst who is skilled at explaining these concepts as they apply to this film, to a lay audience. The students in such a class would already have a keen interest in how movies convey psychological issues and would value seeing this film again (or for the first time) and would most likely be very receptive to having the meaning put in a psychodynamic and psychoanalytic context. Once again this book would be a marvelous textbook for the leader and the group to use after they have seen the film under discussion.
I am very pleased to interview psychiatrist Dr. Jeffery Smith who is the author of a new exciting book titled Getting the Most From Your Therapy- Become An Educated Consumer. Dr. Smith received his medical degree from UCLA and did his residency in Psychiatry at Albert Einstein Medical School in New York. He is an Associate Clinical Professor of Psychiatry at New York Medical College where I first met him before I came out to California. He has written two other books and has a blog about psychotherapy. The following interview is 35 minutes.
Any comments are welcome below. Please click the line below to listen to the interview : Interview with Dr, Jeffery Smith
By Ellen Marie Wiseman
This book is composed of two interweaving stories. Clara, a woman who lived in the 1930s was committed to a mental institution against her will based on her wealthy father’s unhappiness about her Italian immigrant boyfriend and her refusal to marry the rich guy that her father picked out for her. The other story is about a current day teenager named Izzy who is a foster child of Peg and Harry after having lived with several previous foster parents since her mother unexplainably murdered her father. Peg is working on a museum project examining newly discovered suitcases of belongings of former patients (including those of Clara) of a now closed psychiatric facility, in order to gain some understanding of their lives. Izzy helps out with this project and finds the diary of Clara and becomes interested in her life.
Being a psychiatrist, I was initially drawn to this book with the idea that I would gain some insight into the lives and treatments of psychiatric patients living in the first half of the twentieth century. This was the case and it included vivid description of the treatment that was done at that time such as ice baths, insulin shock therapy and electroconvulsive therapy (ECT).
Although I never worked in a state hospital, when I toured them in the late 1960s, such treatments except occasional ECT under humane conditions were things of the past. As far as the possibility of someone spending most of their life committed to a mental institution based on the word of her father when she clearly did not have a mental illness, I would like to think that this would not have been possible. Certainly, in modern times from my experience someone being hospitalized against their will would have to go through a legal hearing with the patient being assigned an attorney if they don’t have one. Once in a hospital with treatment with modern-day medicines (which were not really available until the 1950s) most mental illness can be put at least in temporary remission with such treatment. Today, there would be reviews by multiple doctors with no mandate to keep the person in the hospital against their will unless they were a danger to themselves or others due to a mental illness. I would hope that nothing like Clara’s situation could occur today. Obviously, I can’t speak for every state hospital in the United States and certainly things were different in the 1930s.
There was another aspect of Clara’s case was particularly disturbing to me in that the psychiatrist in charge of her care was depicted as a mean, cruel, selfish man who was mainly responsible for Clara’s lost life. I felt it was an unfair indictment, which suggested all psychiatrists of that time might have been of the same cloth. I understand that the author has the creative choice to develop characters in whatever fashion she chooses. I probably would not be complaining if the character were a dishonest lawyer who did unsavory things in the interest of an interesting storyline but nevertheless, I felt that this book was stigmatizing my profession.
There was particular theme of this book, which also had a special interest to me. Three characters in the book were driven to try to understand their early origins. Izzy, understandably could not fathom why her beloved mother murdered her father. This ultimately led her to empathize with a schoolmate who had some parental trauma. It contributed to her mission to find Clara’s daughter who was essentially separated from her at birth, and hand over her mother’s diaries so she could know about her mother’s story. Clara’s daughter led a life of yearning to know what happened to her mother and Clara similarly went through life wanting to know what happened to her daughter. This is a variation of a theme, which I have seen played out in many people’s lives as well as in some interesting movies. Persons, sometimes separated at birth or when they are quite young often yearn to know their biological parent or parents with whom they may have had no relationship for decades. I have reflected on the psychodynamics of these issues in an earlier posting in this blog. Therefore, I was particularly interested to see how they played out as major motivating factors in the characters in this book.
I believe the author Ellen Wiseman has created an intriguing story that will hold the interest of the reader whether or not you come from a psychiatric background.